Basic Information
| Provider Information | |||||||||
| NPI: | 1619179561 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SAINT LOUIS UNIVERSITY MEDICAL CENTER | ||||||||
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| OtherOrganizationName: | SLUCARE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12455 MARINE AVE | ||||||||
| Address2: | |||||||||
| City: | MARYLAND HEIGHTS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630433633 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3145796159 | ||||||||
| FaxNumber: | 3147718575 | ||||||||
| Practice Location | |||||||||
| Address1: | 1402 S GRAND BLVD # M238 | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631041004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3149778462 | ||||||||
| FaxNumber: | 3147718575 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | WESTWOOD | ||||||||
| AuthorizedOfficialFirstName: | MELISSA | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATIVE SECRETARY | ||||||||
| AuthorizedOfficialTelephone: | 3149778462 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282NC0060X | 2004-012733 | MO | Y | Hospitals | General Acute Care Hospital | Critical Access |
No ID Information.